Free MORBID_OBESITY_1 (57969 - Draft - Indiana

SURGERY FOR THE TREATMENT OF MORBID OBESITY - Page 1 of 2
INITIAL REPORT Indiana State Department of Health State Form 53321 (6-07) DIRECTIONS - PLEASE READ BEFORE YOU BEGIN: 3 Fill in circles like this: 1 Print firmly and neatly. Not like this: 2 Only use pens with blue or black ink. Mark mistakes like this:

Reset Form

4 Print capital letters only and numbers completely inside boxes.

A 2 C 3

5 Please complete all items on form.

Section 1. Patient Information

Last Name

First Name

MI

Phone Number

-

-

Number & Street Address

City

State

ZIP Code

County Sex:
Male Female Unknown

Date of Birth (mm/dd/yyyy) Race (select all that apply):
Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

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/

Age (years)
White Other/Multiracial Unknown

Ethnicity:
Hispanic or Latino Not Hispanic or Latino Unknown

Section 2. Surgery Information

Baseline Measurements (before surgery):
BMI: Comorbidities: Waist Circumference:
Inches

.
.

Previous Abdominal Surgery?

Yes

No

.
ICD-9-CM Code

.
ICD-9-CM Code

.
ICD-9-CM Code

.
ICD-9-CM Code

ICD-9-CM Code

Surgery:
Date of Procedure (mm/dd/yyyy): Surgical Diagnosis ( ICD-9-CM Code):
Diagnosis, description:

/
.

/

Surgical Procedure (CPT Code):
Procedure, description:

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3

SURGERY FOR THE TREATMENT OF MORBID OBESITY - Page 2 of 2
INITIAL REPORT Indiana State Department of Health State Form 53321 (6-07) Section 2. Surgery Information (continued)

Name of Facility Where Surgery Performed

Facility Number & Street Address

City

State

ZIP Code

-

Telephone Number

-

-

FAX Number

-

Surgeon's Indiana License Number

Name of Surgeon

Address

City

State

ZIP Code

-

Telephone Number

-

FAX Number

-

Section 3. Additional Information and Comments Comments:

Last Name of Person Completing Form

First Name of Person Completing Form

Phone Number

-

-

Date Form Completed (mm/dd/yyyy)

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/

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3